B. Meunier

Who Benefits from Portal Vein Resection during Pancreaticoduodenectomy for Pancreatic Cancer

Abstract. Portal vein resection during pancreaticoduodenectomy has recently experienced renewed interest. We describe our results with this procedure over a 20-year period. Among 88 consecutive pancreatectomies for cancer of head of the pancreas, 14 included en bloc removal of the portal vein. There was no hospital mortality. Only 21% were found to have histologically confirmed cancer invasion, and the remainder had inflammatory adherence. Two-year survival was 15% compared to 34% for patients who did not have portal vein resection. There were no 5-year survivors. We discuss our results in light of other recent reports.

Combined radiochemotherapy for postoperative recurrence of oesophageal cancer

Postoperative recurrences are common after resection for oesophageal cancer. From January 1986 to September 1993 31 patients (30 males, one female, mean (SD) age: 57.5 (8.8) years) were treated for locoregional recurrence (n = 24), metastases (n = 6) or both (n = 1) occurring 15.0 (12.6) months after initial surgery. Radiotherapy and chemotherapy were combined in all cases. Symptomatic improvement was seen in 23 cases (74%) and lasted (excluding treatment period) for 6.3 (4) months. Objective tumoral response was seen in 20 patients (65%) including eight (26%) complete responses. Survival rates were at respectively six months, one, two, and three years: 70.7%, 47.1%, 17.1%, 4.3%. In conclusion, these results show that combined therapy could have a beneficial symptomatic effect and can be associated with prolonged survival in patients with postoperative recurrences of oesophageal cancer.

Molecular profiling of stroma identifies osteopontin as an independent predictor of poor prognosis in intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is the second most common type of primary cancer in the liver. ICC is an aggressive cancer with poor prognosis and limited therapeutic strategies. The identification of new drug targets and prognostic biomarkers is an important clinical challenge for ICC. The presence of an abundant stroma is a histological hallmark of ICC. Given the well‐established role of the stromal compartment in the progression of cancer diseases, we hypothesized that relevant biomarkers could be identified by analyzing the stroma of ICC. By combining laser capture microdissection and gene expression profiling, we demonstrate that ICC stromal cells exhibit dramatic genomic changes. We identified a signature of 1,073 nonredundant genes that significantly discriminate the tumor stroma from nontumor fibrous tissue. Functional analysis of differentially expressed genes demonstrated that up‐regulated genes in the stroma of ICC were related to cell cycle, extracellular matrix, and transforming growth factor beta (TGFβ) pathways. Tissue microarray analysis using an independent cohort of 40 ICC patients validated at a protein level the increased expression of collagen 4A1/COL4A1, laminin gamma 2/LAMC2, osteopontin/SPP1, KIAA0101, and TGFβ2 genes in the stroma of ICC. Statistical analysis of clinical and pathological features demonstrated that the expression of osteopontin, TGFβ2, and laminin in the stroma of ICC was significantly correlated with overall patient survival. More important, multivariate analysis demonstrated that the stromal expression of osteopontin was an independent prognostic marker for overall and disease‐free survival. Conclusion: The study identifies clinically relevant genomic alterations in the stroma of ICC, including candidate biomarkers for prognosis, supporting the idea that tumor stroma is an important factor for ICC onset and progression. (Hepatology 2013; 58:1992–2000)

Intra-arterial Yttrium-90 Radioembolization Combined with Systemic Chemotherapy is a Promising Method for Downstaging Unresectable Huge Intrahepatic Cholangiocarcinoma to Surgical Treatment

PurposeTo evaluate the downstaging efficacy of yttrium-90 radioembolization (Ytt-90)-associated with chemotherapy and the results of surgery for initially unresectable huge intrahepatic cholangiocarcinoma (ICC).MethodsBetween January 2008 and October 2013, unresectable ICC were treated with chemotherapy and Ytt-90. Patients with unique tumors localized to noncirrhotic livers and without extrahepatic metastasis were considered to be potentially resectable and were evaluated every 2xa0months for possible secondary resection.ResultsForty-five patients were treated for unresectable ICCs; ten had potentially resectable tumors, and eight underwent surgery. Initial unresectability was due to the involvement of the hepatic veins or portal vein of the future liver remnant in seven and one cases, respectively. Preoperative treatment induced significant decreases in tumor volume (295 vs. 168xa0ml, pxa0=xa00.02) and allowed for R0 resection in all cases. Three patients (37.5xa0%) had Clavien–Dindo grade three or higher complications, including two postoperative deaths. The median follow-ups were 15.6 [range 4–40.7] months after medical treatment initiation and 7.2 [0.13–36.4] months after surgery. At the end of the study period, five patients were still alive, with one patient still alive 40xa0months after medical treatment initiation (36.4xa0months after surgery); two patients experienced recurrences.ConclusionsFor initially unresectable huge ICCs, chemotherapy with Ytt-90 radioembolization is an effective downstaging method that allows for secondary resectability.

New Approach to Surgical Management of Early Esophageal Thoracic Perforation: Primary Suture Repair Reinforced with Absorbable Mesh and Fibrin Glue

Abstract Esophageal perforation is anlife-threatening situation and represents a major therapeuticnchallenge. Results have improved in recent years particularly as anresult of progress in antibiotic therapy and the use of totalnparenteral nutrition. Surgical management retains a predominant role,ninvolving early primary closure and thoracic drainage. We have made annaddition to the surgical management by applying an absorbable mesh andnfibrin glue to the repaired site. Seven patients (ages 38–79 years)nwere treated as described. The mean interval from leak to surgery wasn28 hours. Six patients had an uneventful postoperative course with anmean hospital stay of 34 days (range 26–45 days). In one case thentechnique failed and the patient required an exclusion-diversionnprocedure. All 7 patients recovered without mortality. We believe thatnthis technique provides a real improvement for this precariousnesophageal repair.n

Prognostic factors of the uterine cervix adenocarcinoma

BACKGROUNDnPrognosis factors for adenocarcinoma of the uterine cervix after primary treatment are poorly established.nnnMETHODSnA retrospective study of 45 cases of adenocarcinoma of the cervix with a follow-up of 96 months on average was performed. The primary treatment consisted in combined radical surgery and radiotherapy for stage I-II patients while patients with advanced disease were treated by radiotherapy. In case of poor prognosis factors, they were given chemotherapy. Survival rates were established and prognosis factors influencing survival and recurrences were studied.nnnRESULTSnFifteen women remained alive without evolutive disease. FIGO stage and pelvic node involvement were the most important parameters influencing overall survival. Local failures (27%, average period of 30 months) were unpredictable and led to a dramatic outcome. Histological grade and pelvic node status were significant predictive factors for metastatic recurrence (40%, average period of 29 months).nnnCONCLUSIONSnLocal recurrence and metastatic dissemination of cervical adenocarcinoma after primary treatment prove to be rapidly fatal although life expectancy can be prolonged with adjuvant treatment of the recurrence. In the event of aggressive tumors with high histological grade and pelvic node involvement, an attempt to assess adjuvant systemic chemotherapy could be useful.

Impact of age over 75 years on outcomes after pancreaticoduodenectomy

BACKGROUNDnThe risks associated with pancreaticoduodenectomy (PD) in elderly patients continue to be debated. The aim of our study was to assess the incidence of death and postoperative complications following PD and identify the risk factors in patients >75 y.nnnSTUDY DESIGNnAll patients who underwent PD between January 2000 and September 2009 were analyzed retrospectively. Patients were divided into two groups according to age (Group 1: patients aged <75 y, and Group 2: patients aged ≥ 75 y). Morbidity and perioperative mortality risk factors were analyzed using univariate and multivariate analyses.nnnRESULTSnAmong the 314 patients, 273 were included in Group 1 (sex ratio 1.4) and 41 in Group 2 (sex ratio 1). In multivariate analysis, postoperative hemorrhage (PH) (OR 6.61, IC95% [1.96; 22.31], P = 0.002) and age >75 y proved to be predictive factors for mortality (OR 11.04, IC95% [2.57; 47.49], P = 0.001). When compared with Group 1, Group 2 was associated with increased postoperative deaths (24.4% versus 3.66%, P < 0.001) and pancreatic fistulas (26.8% versus 13.2%, P = 0.041), in particular, Grade C fistulas (14.6% versus 4.4%, P = 0.023). In multivariate analysis, only PH proved to be an independent predictive factor for mortality (OR 12.9, IC95% [1.07; 155.5], P = 0.04).nnnCONCLUSIONSnPD in elderly patients aged over 75 y appears to be associated with an increased risk of postoperative death and pancreatic fistula. No single preoperative factor made it possible to predict this risk.

Three cases of sarcoma occurring after radiation therapy of breast cancers

We report 3 cases of sarcomas following irradiation for breast carcinoma. Median latent period ranged from 7 to 17 years. Histologic types were 1 malignant fibrous histiocytoma, 1 osteochondrosarcoma, 1 chondrosarcoma. Diagnosis was often delayed because of non-specific clinical features. The prognosis of these postirradiation sarcomas was poor with the median survival ranging from 10 to 70 months. One patient had a complete resection and is alive at 70 months. In the other 2 non-resectable patients, chemotherapy and/or radiotherapy did not induce an objective response. The poor prognosis when these tumors are diagnosed late emphasizes the need for increased awareness, which should lead to earlier diagnosis and, it is hoped, permit radical surgical treatment.

MELD-based graft allocation system fails to improve liver transplantation efficacy in a single-center intent-to-treat analysis

BACKGROUNDnSince March 2007, priority access to liver transplantation in France has been given to patients with the highest MELD scores.nnnOBJECTIVEnTo undertake an intent-to-treat comparison of center-based vs. MELD-based liver graft allocation.nnnMETHODSnRetrospective cohort analysis (patients listed 6th March 2007 to 5th March 2009; MELD period) with a matched historical cohort (patients listed 6th March 2005 to 5th March 2007; pre-MELD period) in a single high-volume center. Analysis was on an intent-to-treat basis, i.e. starting on the day of wait listing.nnnRESULTSnCompared to pre-MELD, fewer patients with a MELD score less or equal to 14 (P=0.002), and more patients with a MELD greater or equal to 24 (P<0.05) were transplanted during the MELD period. For HCC candidates, median waiting time increased (121 vs. 54 days, P=0.01), transplantation rate halved (35% vs. 73.5%, P<0.001) and dropouts due to tumor progression increased (16% vs. 0%, P<0.001). Moreover, postoperative course did not change significantly except for infectious complications (35% vs. 24%, P=0.02); overall patient survival was 69.8 ± 3.1% vs. 76 ± 2.9% (P=0.29) and overall graft survival was 77.6 ± 3.4% vs. 82.8 ± 2.9% (P=0.29). Transplant failures were mainly due to deaths on the waiting list in the previous system, but to dropouts related to disease progression in the new system. Cirrhotic patient survival rate did not change (78.1 ± 4.4% vs. 73.5 ± 4.5%, P=0.42), while that of HCC patients decreased (65.3 ± 5.3% vs. 86.8 ± 4.4%, P=0.01). Post-transplant survival worsened significantly according to pre-transplant MELD score (P=0.009).nnnCONCLUSIONnThe MELD-based graft allocation system introduced discrimination against HCC patients, whose incidence has increased dramatically, and should be reevaluated.

Use of temporary porto‐caval shunt during liver transplantation with inferior vena cava conservation: An effective method to enhance use of octogenarian graft?

We read with great interest the study of Ghinolfi et al. and wanted to congratulate them for their work. The authors reported their series of 123 liver transplantations (LTs), which were performed with the retrohepatic inferior vena cava (IVC) replacement technique and venovenous bypass, using octogenarian grafts, and they found that donor hemodynamic instability, diabetes mellitus, and donor age–Model for End-Stage Liver Disease (D-MELD) were predictive of higher incidence of ischemic-type biliary lesion incidence in the multivariate analysis. In our center, we routinely perform LTs with retrohepatic IVC preservation and side-to-side cavocaval anastomosis. According to surgeon preference, a temporary portocaval shunt (TPCS) is performed or not. From January 2007 to December 2014, 816 transplantations were performed in our institution, and using the same selection criteria as Ghinolfi et al., we identified 48 LTs performed using octogenarian donors. TPCS was performed in 31 patients and absent in 17 patients. We found that octogenarian graft survival was significantly improved when a TPCS was performed (P 5 0.02; Fig. 1A).We also observed a significant reduction of alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT) levels in the early postoperative days (PODs), whereas bilirubin levels were similar (Fig. 1B-D). The IVC preservation technique is currently preferred to the IVC replacement technique. In this situation, we found that use of TPCS improves octogenarian graft outcome and biliary biological parameters in the early PODs. Interest of TPCS has been previously shown, and some authors also reported improvement of longterm graft survival. However, these results were not specifically focused on octogenarian grafts. The beneficial effects of TPCS might be explained by the improvement of the recipient’s intraoperative hemodynamic status, a decrease of postreperfusion syndrome incidence, or prevention of splanchnic congestion. In conclusion, we agree with Ghinolfi et al. regarding the safety of octogenarian grafts, and we think that TPCS should be recommended when vena cava preservation is performed, in order to improve outcomes and biliary function in this situation.